Cirrhosis: It’s not just related to alcohol!

The liver weighs about 2 kg and is the second largest organ in the human body after the skin. However, the significant role that it plays is what makes it a vital organ.

The liver does the following [1]:

• Filters substances from the digestive tract and breaks down potential toxins, such as alcohol, to ultimately eliminate them in the bile or urine.
• Stores dietary nutrients, such as iron and vitamins.
• Metabolizes many of the molecules present in the blood. The liver is also the main producer of glucose during episodes of hypoglycemia, and urea once proteins have been broken down.
• Synthesizes most blood proteins.

The liver, looking like a soft sponge, is made up of thousands of small channels called sinusoids. These channels allow exchanges between blood, which is rich in nutrients and toxins, from the digestive tract via the portal vein, and oxygenated blood from the hepatic artery. The liver contains about 10% of the body’s total blood by volume, and blood flow in the liver is powerful: more than 1.4 L passes through every minute.

The walls of the liver are made up of a single layer of cells, called hepatocytes, where all liver functions occur. A system of veins and bile ducts allows the blood to flow back into general circulation and evacuates bile into the small intestine [2].

Even though the liver is a large organ with crucial functions, symptoms of liver disease often only become apparent once the organ is severely compromised.

The main symptoms of liver disease are [3]:

• Jaundice: yellowing of the skin and the whites of the eyes
• Abdominal bloating and pain
• Swelling of the legs and hips
• Dark urine and light-coloured stool
• Constant fatigue, nausea and vomiting
• Loss of appetite
• Bruising on the skin

Chronic viral infections, such as hepatitis B and C, genetic factors, such as Wilson’s disease, and alcohol abuse were long considered the main causes of severe liver disease. Over time, it has become obvious that other unhealthy lifestyle habits are also responsible for a growing number of terminal liver diseases, including cirrhosis.

The liver is a unique organ. Unlike other organs, it is able to regenerate! When part of the liver is removed, it can recreate the missing tissue within a few months and resume its original shape. However, this regeneration process is accompanied by the formation of connective tissue that reduces the number of hepatocytes and decreases the liver’s elasticity. Over time, the continuous regeneration of dead hepatocytes results in an accumulation of fibrous tissue, which is known as hepatic fibrosis. The presence of fats in the liver is a major cause of this kind of fibrosis.

Nonalcoholic fatty liver disease (NAFLD) is characterized by fat accumulation in more than 5% of the liver, whereas nonalcoholic steatohepatitis (NASH) refers to the same condition when inflammation is also present. When fibrosis becomes so extensive that the liver no longer contains enough hepatocytes to carry out its many functions and blood flow in the organ is compromised, this is then referred to as cirrhosis.

Cirrhosis is associated with additional complications [3]:

• Esophageal (upper gastrointestinal) bleeding
• Accumulation of fluid in the abdominal cavity (ascites)
• Deterioration of brain function (hepatic encephalopathy)
• Increased risk of liver cancer (hepatocellular carcinoma)

The only treatment currently available for cirrhosis is a liver transplant. For this reason, prevention is extremely important, particularly since cirrhosis can develop without showing any obvious symptoms. Liver disease is often found during regular medical check-ups or diagnostic tests for another disease.

The diagnosis and monitoring of liver disease relies on several techniques:

• Liver biopsy, which involves inserting a long needle between two ribs to remove a small sample of liver tissue, which will be analyzed under a microscope by an anatomical pathologist.
• Imaging, and ultrasound in particular. Computerized axial tomography (CAT) scans can be used to visualize damage to the adjacent structures of the liver.
• Elastography, or FibroScan, an ultrasound technique that makes it possible to assess the loss of liver tissue elasticity as a result of fibrosis.

A liver profile includes the following tests:

• ALT and AST
• Total and direct bilirubin
• ALP and GGT
• Albumin

Many other tests may be performed depending on the person’s situation, such as:

• Hepatitis B and C serology
• Type 2 diabetes screening
• Lipid profile
• Autoimmune liver disease markers
• Liver cancer markers (alpha-fetoprotein)
• Complete blood count and coagulation tests
• Genetic markers of liver disease (ELF, ceruloplasmin)

The enhanced liver fibrosis (ELF) test uses a mathematical algorithm to measure three direct markers of fibrosis, including procollagen. Even though this test is still difficult to access in public laboratories, it is an effective way to regularly evaluate the progression of fibrosis, avoiding the need for performing repeated biopsies. This test has been recommended by health authorities in the U.K. for several years now [4].

The FIB-4 test, or Fibrosis-4 Index, is another common way of screening for liver fibrosis. Using routine laboratory tests, an algorithm calculates a score to assess the presence of liver fibrosis. This test can be used ahead of other, more complex, tests where liver damage is suspected.

Steatosis occurs when there is excess fat (cholesterol and triglycerides) and sugar (glucose and other forms of sugar) in your diet, or when your body has difficulty metabolizing them, such as in cases of obesity, type 2 diabetes, metabolic syndrome, high cholesterol and high triglyceride levels.

With the surge of obesity in Western societies and, by extension, the number of cases of type 2 diabetes, there has been a significant increase in the number of cases of nonalcoholic fatty liver disease, which may progress to cirrhosis.

Previously little known, nonalcoholic fatty liver disease now affects almost a quarter of all Canadians and might become the leading cause of liver transplants in the coming years. According to Dr. Giada Sebastiani, hepatologist at the McGill University Health Centre (MUHC), we are going to see a tsunami of cases of cirrhosis. The culprit? A poor diet, with too much fat and sugar, and fatal consequences for the liver [5].

Changing your lifestyle is still the most effective treatment for fatty liver disease, since there is currently no drug therapy approved in Canada.

The recommendations for maintaining a healthy liver are the same as the ones that help you prevent obesity, reduce the risk of cardiovascular disease and lower the risk of certain types of cancer. A balanced diet and regular physical exercise are crucial.

• Drink water instead of sweetened drinks
• Reach for whole foods such as fresh fruits and vegetables and whole grains, while limiting ultra-processed foods
• Snack on fruits and vegetables
• Opt for plain yogourt and add berries
• Spread whole grain bread with cheese, avocado or nut butter

The Centre hospitalier universitaire de Québec recommends moving for at least 150 to 200 minutes a week. It is recommended that you do three to five weekly sessions of moderate-intensity aerobic activity, such as brisk walking, cycling or hiking. More intense activity, such as resistance training, provides even more protection against metabolic syndrome and NAFLD [7].

Children are not immune from fatty liver disease. More and more children are affected, largely due to the alarming increase in childhood obesity and very low levels of physical activity [8].

• Fatty liver disease affects almost 3% of all children and 22% to 53% of obese children.
• Fatty liver disease has been observed as early as 2 years of age.

Nonalcoholic fatty liver disease can lead to cirrhosis and liver cancer in 20 to 30 years [5], meaning that more and more young adults may need a liver transplant. However, the disease is reversible if it is managed early on. So, you need to stay alert and adopt a healthy lifestyle!